The ATSB’s final investigation report into a signal passed at danger (SPAD) event, involving suburban passenger train near Roma Street Station, Brisbane, Queensland, on 5 September 2017 demonstrates how task-irrelevant thoughts can contribute to driver distraction and decrease task performance.

Report summary:

The ATSB investigation found task-irrelevant thoughts contributed to the driver’s distraction from observing and reacting appropriately when a stop signal approximately 140m west of platform 8 at Roma Street Station. Task-irrelevant thoughts can increase based on a person’s emotional state or mood. In this instance, the driver advised they recalled a significant past event prior to commencing work that resulted in an emotional response.

A PEAK-HOUR train crash at one of Brisbane’s busiest stations was narrowly averted after a driver ran a red light.

The near-miss at Roma St last September is detailed in an investigation report issued today by the Australian Transport Safety Bureau.

It says the driver was distracted by “emotional thoughts” when he ignored the red stop signal and continued on to the platform in the station at about 4.30pm on September 5.

At the same time, another train was travelling in the opposite direction from central station on ‘’a converging route”.

An alarm activated at the Queensland Rail Management Centre and the network control officer broadcast an emergency radio message, telling both drivers to stop.

The vehicles were about 550 metres apart when they came to a halt.

The incident caused chaos, with commuters facing delays for hours after the incident which Translink described as a “points issue” at the time.

The ATSB report says the train 1W33 was being taken from the Mayne Depot on the Exhibition loop line without any passengers aboard.

As it approached Roma St from the west, the driver acknowledged a flashing yellow signal warning him to slow to 25km/h.

But he went through last signal before the station which was red.

“The ATSB found that the driver of 1W33 was distracted from his primary task of driving the train, including observing and reacting to signals, by personal emotional thoughts when approaching signal RS57 displaying a stop indication,” the report says.

“In relation to this incident, the driver advised that prior to commencing work he recalled a significant past personal event that resulted in an emotional response.”

The ATSB report says Queensland Rail has already taken action in response to the incident including raising the volume of audible warnings at yellow and red signals.

They have also developed a health and wellbeing strategic plan including an organisational resilience and psychological wellbeing education and awareness program.

QR has also sought tenders to implement the European Train Control System which has additional inbuilt automated safety control features.

Without wishing to sound alarmist can the Minister please outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs might be disturbing to some of the public.

Signal ME45 passed at danger resulting in a near-miss between suburban passenger trains TP43 and TR50 at Bowen Hills, Queensland on 10 January 2018

The ATSB has commenced an investigation into a signal passed at danger (SPAD) rail occurrence that occurred near Bowen Hills station in Brisbane, Queensland on 10 January 2018.

Suburban passenger train, designation TP43, exceeded its limit of authority by passing signal ME45 at danger, and continued on as the driver at the controls was unaware of the occurrence. At this point there was an imminent risk of a collision, as train TP43 was travelling directly into the path of suburban train TR50.

The train controller, who was alerted to the SPAD by the activation of a systems warning alarm, was able to broadcast an emergency call to the driver of train TP43, who subsequently stopped the train prior to the point of conflict. As part of the investigation, the ATSB will be collecting evidential material to determine the safety factors which contributed to the SPAD occurrence.

A final report will be released at the end of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify those affected and seek safety action to address the issue.

As we anticipated, feedback indicates passengers are concerned with the increasing incidence of SPADs on the Citytrain network.

We again call for the Minister to outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs is disturbing to some of the public.

Without wishing to sound alarmist can the Minister please outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs might be disturbing to some of the public.

A TRAIN driver was back behind the controls 19 days after narrowly avoiding a collision at a busy Brisbane railway station when he became distracted and ran a red stop signal.

The incident was among those making up a “disturbing” rise in train drivers running red signals on the Citytrain passenger network.

Queensland Rail figures released to The Sunday Mail reveal 2017 was the worst year in almost a decade for drivers running red signals, with 38 “signals passed at danger” (SPAD) incidents that year. The number of incidents continued to climb in the first half of 2017-18.

Most recently, a train ignored a red signal on January 10 at Bowen Hills station, creating an “imminent risk of a collision” with a suburban train, according to the Australian Transport Safety Bureau, which is still investigating the incident.

In a separate incident on September 5 last year, the driver of an empty train ignored a red signal and continued on to the Roma St platform, coming within 550m of a train on a converging route.

No one was injured, but it threw the network into chaos during afternoon peak hour.

An ATSB investigation this month found the red stop was missed after the driver became distracted by “personal emotional thoughts”.

“The driver advised that prior to commencing work he recalled a significant past personal event that resulted in an emotional response,” it found.

It also revealed drivers had run red lights at the same signal six times since 2007.

QR said the driver was cleared to return to work less than three weeks later.

QR chief executive officer Nick Easy rejected any link between the number of incidents and the ongoing train crew shortage, and said drivers must pass a competency test and on-track monitoring to check their skills before being deemed fit to return to duty.

But state Opposition Leader Deb Frecklington said the spike coincided with major service cutbacks due to the driver shortage, and criticised QR for not having a permanent safety manager.

She also labelled the Labor Government’s handling of rail safety as “disturbing”.

An increasing number of passengers are becoming very uneasy with the rising incidence of SPADs. This is not an April Fools joke. This is alarming.

Is there a link for the increasing incidence of SPADs with factors such as excess overtime, substance abuse, and the fixation on ontime running peak statistically nonsensical KPIs? Have braking issues with the New Generation Rollingstock trains also been a factor?

As we anticipated, feedback indicates passengers are concerned with the increasing incidence of SPADs on the Citytrain network.

We again call for the Minister to outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs is disturbing to some of the public.

Without wishing to sound alarmist can the Minister please outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs might be disturbing to some of the public.

COMMUTERS are being put at risk by train drivers who run red lights while chatting, speeding, eating snacks or daydreaming, as the rate of close-calls climbs.

But last year’s timetable bungle was also partly blamed for an error that saw a driver blow through a red signal by 150m and ignore a back-up alarm warning.

The Courier-Mail can reveal the bungles outlined in official safety reports that have seen trains chug past stops by as much as 900m, with several having the potential for collision as ignorant passengers sat on board.

Safety investigation reports obtained under Right to Information laws identified drivers who were speeding, chatting with a guard, eating, distracted by a crackly radio, had their emergency broadcast turned down, or were thinking about personal issues when they recorded a Signal Passed at Danger (SPAD).

Several would have headed into the path of another train had emergency systems not kicked in. All were cleared for drugs and alcohol, and ­fatigue was thought to be a contributory factor in just one case, although another driver admitted he had got behind the controls after only five hours’ sleep.

Documents outline a December 11 incident in which a Shorncliffe service damaged track points after it drove on to a section set for a Cleveland-bound train that had passed by just 22 seconds ­earlier between Nundah and Northgate stations. The Shorncliffe driver read the wrong light and thought a warning alarm that sounded was a “fault”. It wasn’t until network control sent an emergency call that she braked to stop, overshooting the signal by 147m.

The investigation found that “the October timetable required a number of complex train movements through Northgate Station”.

An investigation into another SPAD at Northgate on November 20 found the “potential to result in a flanking collision” as two trains headed towards the platform on the same piece of track.

Both trains were ordered to apply emergency brakes when one driver misread a signal and was travelling too fast on approach to the red.

QR’s figures show the incidents of SPAD events trending up since January 2016.

There have been 27 since August last year, not including those caused by third party operators Aurizon and Pacific National, and the organisation is averaging one a week.

QR chief executive Nick Easy said the organisation was reviewing its SPAD Risk Reduction Strategy, but he said the number of events was consistent with the monthly average for the past five years of 3.6.

“Safety is Queensland Rail’s absolute priority and we have a comprehensive strategy in place and a broad range of safety controls, from engineering design of the signalling system to driver training and cultural awareness programs,” he said. “SPAD incidents are an industry-wide occurrence, but when you look at the data our strategy is working.”

Transport Minister Jackie Trad (pictured) said she was confident QR was “doing everything it can to improve safety and reduce SPADs”.

Rail Tram and Bus Union state secretary Owen Doogan said no SPADs had resulted in injuries and the current rate was “pretty good”.

The Australian Transport Safety Bureau has released the final investigation report into an incident on 26 August 2017 involving a ‘signal passed at danger’ by suburban passenger train 1A21 in Bowen Hill, Queensland.

Report summary:At about 0948, suburban passenger train 1A21 exceeded its limit of authority by passing signal ME45 while it displayed a stop indication. The driver of the train was distracted on approach to Bowen Hills station and was further distracted after departing from the station. The sequence of distractions led to the driver overlooking risk control measures that would normally be applied when approaching a stop signal. This resulted in the driver applying the brakes too late to stop before the signal. The signal had been placed at ‘stop’ to define the limit of a Track Occupancy Authority, which was in the process of being lifted for normal operations.

This incident serves as an important reminder to train drivers that distraction while operating trains is a hazard which increases risk. To manage the risk appropriately, drivers are required to follow a robust risk-based approach. This includes applying the appropriate procedures and control measures

No response to our request for a detailed explanation as to what is being done to review Signal Passed At Danger (SPAD) events. We understand there was another SPAD last evening.

It is disappointing that the ' State of Queensland ' ignores the growing community unease with respect to SPADs and fails to outline what is being done to bring SPADs down. Queensland Government and their bureaucracies are not transparent and open. They are in fact cloistered and secretive in the extreme, which breeds cultural and organisational failure. Something we are all far to familiar with sadly.

An increasing number of passengers are becoming very uneasy with the rising incidence of SPADs. This is not an April Fools joke. This is alarming.

Is there a link for the increasing incidence of SPADs with factors such as excess overtime, substance abuse, and the fixation on ontime running peak statistically nonsensical KPIs? Have braking issues with the New Generation Rollingstock trains also been a factor?

As we anticipated, feedback indicates passengers are concerned with the increasing incidence of SPADs on the Citytrain network.

We again call for the Minister to outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs is disturbing to some of the public.

Without wishing to sound alarmist can the Minister please outline what is being done to review SPADs and what are the actual steps being taken to reduce their occurrence please? This news of increasing incidence of SPADs might be disturbing to some of the public.

STRESSED, distracted and unhappy Queensland Rail train drivers were behind the controls during some of the worst errors jeopardising passenger safety on the rail network.

A Sunday Mail investigation into a reported spike in the number of train drivers failing to stop at red signals shows the incidents were caused by everything from a driver’s fear about running late to chatty train guards in the driver’s cab and a cabin mishap involving a controller becoming entangled in a telephone cord, causing a power surge.

The incidents are detailed in 24 separate “Signal Passed at Danger (SPAD)” investigations by QR obtained by The Sunday Mail under Right to Information legislation.

Others remain under investigation by the rail safety regulator, including a near-miss on January 10 creating an “imminent risk” of a head-on between two trains at Bowen Hills.

QR faced its worst year in almost a decade for SPAD incidents last year, with 38 cases.

Rail bosses are so concerned they appointed a special taskforce to arrest the upward trend.

In one case, a train driver failed to stop at a red signal in July last year after becoming distracted by fears the train would miss QR’s stringent on-time running targets.

On-time-running is tied to executive bonuses for meeting targets and hefty penalties for not.

It is used by the State Government as a yardstick for QR’s performance, but has been accused of encouraging “station skipping”, where all-station trains are suddenly flicked to run express.

As previously revealed, the trains are then counted as on-time, helping QR meet the nation’s toughest target of 95 per cent of trains arriving within four minutes of the scheduled time.

QR investigators found that the primary cause of the July 2017 incident was a driver becoming “distracted by on-time running requirements and allowing their attention to be drawn away from the primary task of observing signals and responding (to the red signal).”

As passenger train TP37 zoomed toward Albion station that month, the driver’s thoughts were fixed on how the train could ever arrive on time after a series of delays.

A track closure and speed restrictions meant it was running nine minutes late when the driver’s thoughts “digressed” to the domino effect this would have on his later journeys.

It was at this point the driver realised the train was about to whiz by a red light.

STRESSED, distracted and unhappy Queensland Rail train drivers were behind the controls during some of the worst errors jeopardising passenger safety on the rail network.

A Sunday Mail investigation into a reported spike in the number of train drivers failing to stop at red signals shows the incidents were caused by everything from a driver’s fear about running late to chatty train guards in the driver’s cab and a cabin mishap involving a controller becoming entangled in a telephone cord, causing a power surge.

The incidents are detailed in 24 separate “Signal Passed at Danger (SPAD)” investigations by QR obtained by The Sunday Mail under Right to Information legislation.

Others remain under investigation by the rail safety regulator, including a near-miss on January 10 creating an “imminent risk” of a head-on between two trains at Bowen Hills.

QR faced its worst year in almost a decade for SPAD incidents last year, with 38 cases.

Rail bosses are so concerned they appointed a special taskforce to arrest the upward trend.

In one case, a train driver failed to stop at a red signal in July last year after becoming distracted by fears the train would miss QR’s stringent on-time running targets.

On-time-running is tied to executive bonuses for meeting targets and hefty penalties for not.

It is used by the State Government as a yardstick for QR’s performance, but has been accused of encouraging “station skipping”, where all-station trains are suddenly flicked to run express.

As previously revealed, the trains are then counted as on-time, helping QR meet the nation’s toughest target of 95 per cent of trains arriving within four minutes of the scheduled time.

QR investigators found that the primary cause of the July 2017 incident was a driver becoming “distracted by on-time running requirements and allowing their attention to be drawn away from the primary task of observing signals and responding (to the red signal).”

As passenger train TP37 zoomed toward Albion station that month, the driver’s thoughts were fixed on how the train could ever arrive on time after a series of delays.

A track closure and speed restrictions meant it was running nine minutes late when the driver’s thoughts “digressed” to the domino effect this would have on his later journeys.

It was at this point the driver realised the train was about to whiz by a red light.

Previous requests as to a reason as to why the data has not been published have remain unanswered and ignored.

There is growing concern that there may be significant deterioration in some of the key performance data measurements (e.g. signals passed at danger) and this is perhaps why it has not been made available publicly. There is one exception, we have seen skipped stations data for February, March and April 2018. This data was released to a journalist and was reported on 9 News.

If there is not a response by the 13th July 2018 we will make a Right To Information application for the Queensland Rail performance data.

There is something seriously wrong with the Transport Portfolio. There appears to be a deliberate policy of obfuscation and unacceptable delay.

I have seen the skipped stations data for February, March, and April 2018. So there is no doubt that the data is available at Queensland Rail but they don't appear to be able to publicly publish the data. I strongly suspect that the Minister for Transport's office is blocking publication. The question must be asked why?

Data such as Signal Passed At Danger (SPAD), Customer Injuries, Bridge Strikes, Level crossing collisions, and Alcohol and other drugs testing; need to be reported publicly and in a timely manner. The last data published was January 2018.

This lack of publication is unsatisfactory and raises great concerns. These things need to be reported monthly and promptly.

It is difficult to have any confidence in a Government that seeks to obfuscate. Can we have confidence in the rail network?

PoliticalFootball

" QR has rejected a link between the number of SPADs on the network and train crew supply.

What a crock. They're doing huge amounts of OT to cover services. Leave is being knocked back left right and centre for drivers because they don't have enough coverage. The shift turn arounds are rediculous in some instances but because the QR fatigue score is calculated by a computer they think everything is ok.

Staff are only human. They're being pushed beyond acceptable limits of work & fatigue. Add on to that all the extra signals and signs added to the network over the years, it's no wonder incidents have gone up. I would dare say the network is overdue for a major incident.

Of course this all falls on deaf ears though, as long as management keep getting their performance bonuses they don't care about the little bloke.

- Trains skip stops because of network issues and to satisfy metrics. Claims that a private operator would skip stops such as in Melbourne are unsound because the same behavior is observed with a fully public operator as well. Suggests that the actual issue is expectations, contract design, the metrics and pressure to comply rather than public/private.

- Also suggests that guards can decrease the safety of rail operations through distraction. This is evidence against the idea that guards always enhance safety and thus a transition to DOO would reduce safety.

Another observation is that the SPADS metric is too simplistic. It treats a 1m signal violation the same as a 95m violation. Clearly, the risk of a crash increases as the distance travelled past the danger signal increases also.

In other words, the actual graph or chart the CEO is using to suggest QR has reduced SPADS by 5% is itself not properly reflecting the true risk. SPADS should also be measured as a distance, not just a count. A true reduction in risk should see the total distance of SPADS fall.

Negative people... have a problem for every solution.Posts are commentary and are not necessarily endorsed by RAIL Back on Track or its members. Not affiliated with, paid by or in conspiracy with MTR/Metro.